Reducing the prevalence of smokeless tobacco in an evolving tobacco landscape
Authors: Filippos T Filippidis
Journal: The Lancet Global Health (2023)

The global tobacco market is arguably the most diverse it has ever been. Over the past decade, tobacco control policies have led to bans and restrictions of certain types of cigarettes and other tobacco products in some places (eg, menthol cigarettes in the EU and gutka in India). Nevertheless, the tobacco industry has responded by greatly enhancing its portfolio with the introduction of products such as heated tobacco, electronic cigarettes, and flavoured cigarette capsules, which often attract the interest of stakeholders and researchers.1WHOWHO report on the global tobacco epidemic 2021: addressing new and emerging products. World Health Organization, Geneva2021Google Scholar In contrast, smokeless tobacco has not received enough attention at the global level, despite there being more than 300 million smokeless tobacco users, and more than 650 000 deaths are attributed to it annually.2Niaz K Maqbool F Khan F Bahadar H Ismail Hassan F Abdollahi M Smokeless tobacco (paan and gutkha) consumption, prevalence, and contribution to oral cancer.Epidemiol Health. 2017; 39e2017009Crossref PubMed Scopus (109) Google Scholar, 3Siddiqi K Husain S Vidyasagaran A Readshaw A Mishu MP Sheikh A Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries.BMC Med. 2020; 18: 222Crossref PubMed Scopus (70) Google Scholar The systematic review in The Lancet Global Health by Aastha Chugh and colleagues4Chugh A Arora M Jain N et al.The global impact of tobacco control policies on smokeless tobacco use: a systematic review.Lancet Glob Health. 2023; 11: e953-e968Summary Full Text Full Text PDF Scopus (1) Google Scholar is a case in point. Smokeless tobacco is not a novel product and has been around and popular for many decades, especially in particular geographical regions. However, this is only the first systematic review of the impact of tobacco control policies on the prevalence of smokeless tobacco and, as such, fills an important gap in the literature. A key finding of this work is that dozens of countries have already implemented a wide range of tobacco control policies targeting smokeless tobacco use. These policies range from the typical approaches that form the core of the Framework Convention on Tobacco Control and WHO's MPOWER package, such as taxation, health warnings, and advertising bans, to smokeless tobacco-specific policies that fall outside the Framework Convention on Tobacco Control provisions, including complete sales bans and spitting bans. What we also learn from this systematic review is that these policies largely work, which is not surprising at all. The MPOWER policies have been shown repeatedly to be effective, and millions of lives have been saved over the past two decades thanks to their implementation.5Levy DT Li Y Yuan Z Impact of nations meeting the MPOWER targets between 2014 and 2016: an update.Tob Control. 2020; 29: 231-233PubMed Google Scholar This finding should encourage governments to target smokeless tobacco use using the full arsenal of tobacco control policies at their disposal, especially in places where the prevalence of smokeless tobacco use remains high. However, there are a few key questions that this systematic review could not answer. The authors point to a lack of consistency, not only in defining and evaluating policies that are relevant to smokeless tobacco, but even in explicitly identifying smokeless tobacco as a target of tobacco control policies. Smokeless tobacco can be quite different from smoking tobacco and other tobacco and nicotine products in many aspects. Not addressing these differences explicitly in government regulations can create loopholes and reduce the adherence to and efficacy of tobacco control measures.6Siddiqi K Islam Z Khan Z et al.Identification of policy priorities to address the burden of smokeless tobacco in Pakistan: a multimethod analysis.Nicotine Tob Res. 2020; 22: 2262-2265Crossref PubMed Scopus (7) Google Scholar Similarly, ignoring such differences in the scientific literature can confound results and fail to recognise that tobacco control policies could have differential impact on various tobacco products. Most importantly, the existing literature, which Chugh and colleagues4Chugh A Arora M Jain N et al.The global impact of tobacco control policies on smokeless tobacco use: a systematic review.Lancet Glob Health. 2023; 11: e953-e968Summary Full Text Full Text PDF Scopus (1) Google Scholar reviewed, cannot fully account for the ever-changing context of the national and local tobacco landscape. Tobacco products do not exist in isolation. Even where smokeless tobacco has a distinct presence linked to the local culture, it competes with a myriad of other products. These products are frequently taxed differently and are not equally affordable, with smokeless tobacco typically subject to lower taxation compared with smoking tobacco.7Kyriakos CN Ahmad A Chang K Filippidis FT Price differentials of tobacco products: a cross-sectional analysis of 79 countries from the six WHO regions.Tob Induc Dis. 2021; 19: 80Crossref PubMed Google Scholar Differences in affordability often create a dynamic in which users transition from one to another in complex trajectories or use them concurrently, potentially as a cost-minimisation strategy.8Chen DTH Nargis N Fong GT Huq SM Quah ACK Filippidis FT Perceptions and reasons for quitting and transitioning between smoking and smokeless tobacco products: findings from four waves of the ITC Bangladesh survey.Tob Induc Dis. 2023; 21: 25Crossref PubMed Scopus (2) Google Scholar As a result, any evaluation of smokeless tobacco taxation measures should ideally consider the relative cost and concurrent taxation changes in other tobacco products. A plethora of other factors, such as tobacco industry interference, marketing, and promotion of novel tobacco products, perceived harmfulness relative to smoking tobacco, and shifts in the population's lifestyle and culture can heavily influence the prevalence and consumption of smokeless tobacco and, arguably, all the other products it is competing with. Therefore, evaluating the effectiveness of individual tobacco control policies on any single product is a challenging task. This is not to say that we should doubt that tobacco control works; the evidence is overwhelming1WHOWHO report on the global tobacco epidemic 2021: addressing new and emerging products. World Health Organization, Geneva2021Google Scholar, 5Levy DT Li Y Yuan Z Impact of nations meeting the MPOWER targets between 2014 and 2016: an update.Tob Control. 2020; 29: 231-233PubMed Google Scholar and there is no reason to believe that these policies would not apply to smokeless tobacco. However, we must acknowledge that the tobacco and nicotine landscape is not static. The range of products available to consumers today is much greater than 15–20 years ago, when the Framework Convention on Tobacco Control was developed. It might be time for WHO and the global tobacco control community to address each product more explicitly and establish guidance for legislators and researchers, which will facilitate the development and evaluation of the most effective policies for each tobacco product. To this end, the systematic review by Chugh and colleagues4Chugh A Arora M Jain N et al.The global impact of tobacco control policies on smokeless tobacco use: a systematic review.Lancet Glob Health. 2023; 11: e953-e968Summary Full Text Full Text PDF Scopus (1) Google Scholar can be a valuable starting point for policies related to smokeless tobacco. I declare no completing interests. The global impact of tobacco control policies on smokeless tobacco use: a systematic reviewMany countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use. Full-Text PDF Open Access